2 Lumbar Puncture: Indications and Procedure Prepared by Dr. Manal Moussa Ibrahim
3 Session Objectives- Discuss the indications and contraindications for lumbar puncture (LP).- Review the procedure of LP.- Present techniques to minimize post LP headache.
4 Indications for Lumbar Puncture - Diagnosis of central nervous system (CNS) infection.- Diagnosis of subarachnoid hemorrhage (SAH).- Evaluation and diagnosis of inflammatory CNS processes.- Infusion of anesthetic, chemotherapy, or contrast agents into the spinal canal.- Treatment of intracranial hypertension.15% Of seizures result in injury or deathHead contusions and lacerations commonMortality rates1.2% of all seizures3 to 26% in SEMortality rate 10 times higher in adults (vs children)SE mortality highest with hypoxic or ischemic insultDeLorenzo et al. Neurology 1996;46:1029; J Clin Neurophysiol 1995;12:316;Epilepsia 1992;33(Suppl 4):S15. Hauser. Neurology 1990;40(Suppl 2):9. Kirby andSadler. Epilepsia 1995;36:25. Terrence et al. Ann Neurol 1981;9:458.
5 Contraindications - Skin infection near site of LP. - Alteration of intracranial pressure due to cerebral mass.- Uncorrected coagulopathy.- Acute spinal cord trauma.
6 Lumbar puncture procedure Equipment:- 18G or 20G sterile spinal needle with stylet(22G needle for children).-Three-way stopcock.- Manometer.Small adhesive bandage.-- Sterile gloves for the physician.- Sterile gloves for the nurse.- Sterile gauze pad.
7 Equipment: Cont. - Antiseptic solution (e.g. Iodine). - 25G sterile needle for injecting anesthetic.- Three sterile collection tubes with stoppers.- Overbed table.- 3-ml syringe for local anesthetic.- Laboratory request forms and laboratory biohazard transport bag.- Labels and light source.- Disposable lumber puncture trays contain most of the needed sterile equipment.
8 Preparation: 1- Determine whether written consent for the procedure has been obtained.2- Explain the procedure to the patient.3- Instruct the patient to void before theprocedure.
9 Performance:1- The patient is positioned on lateral recumbent position or sitting upright position.2- Small pillow may be placed under the patient's head.3- A pillow may be placed between the legs.4- The patient is encouraged to relax and is instructed to breathe normally.5- The physician cleanses the puncture site with an antiseptic solution and drapes the site.
12 Skin Preparation - Overlying skin cleaned with povidone-iodine. - Sterile drape placed with an opening over the LS.
13 Performance: Cont.6- The physician injects local anesthetic to numbthe puncture site.7- The physician inserts a spinal needle into thesubarachnoid space through the third andfourth or fourth and fifth lumber interspace.8- A specimen of CSF is removed and usuallycollected in three test tubes, labeled in order ofcollection.9- A pressure reading may be obtained.10- The needle is withdrawn.
14 Performance: Cont.11- The physician applies a small dressing to thepuncture site.12- The tubes of CSF are sent to the laboratoryimmediately.13- Instruct the patient to lie prone for 2 to 3 hours.14- Monitor the patient for complications of lumberpuncture.15- Notify physician if complications occur.16- Encourage increased fluid intake.
15 17- Documentation:- Record the initiation and completion of the procedure.- Patient's response.- Administration of drugs.- Number of specimen tubes collected.- Time of transport to the laboratory.- Specimen color, and any other characteristics.
16 Positioning: Key to Success - Fetal position with neck, back, and limbs held in flexion.- Lower lumbar spine flexed with back perfectly perpendicular to edge of bed.- Hips and legs should be parallel to each other and perpendicular to table.
17 Spinal Needle Insertion - Local anesthesia infiltrated.- 20 or 22 gauge spinal needle with stylet.- Advance spinal needle slowly, angling slightly toward the head.- Flat surface of bevel of needle positioned to face patient’s flanks.15% Of seizures result in injury or deathHead contusions and lacerations commonMortality rates1.2% of all seizures3 to 26% in SEMortality rate 10 times higher in adults (vs children)SE mortality highest with hypoxic or ischemic insultDeLorenzo et al. Neurology 1996;46:1029; J Clin Neurophysiol 1995;12:316;Epilepsia 1992;33(Suppl 4):S15. Hauser. Neurology 1990;40(Suppl 2):9. Kirby andSadler. Epilepsia 1995;36:25. Terrence et al. Ann Neurol 1981;9:458.
18 Post-LP Headache- Etiology: Prolonged leakage of cerebrospinal fluid due to delayed closure of dural defect.- Low CSF pressure.- Incidence 1-70%.- Contributing factors:- Diameter of needle, shape of needle, diagnostic vs. spinal anesthesia.
19 Minimizing Post-LP Headache - Techniques:- Needle choice.- Number of attempts.- Reinsertion of Stylet.- Bed Rest after Procedure.